The impact of bronchiectasis associated to sinonasal disease on quality of life

[Management of adult bronchiectasis - Consensus-based Guidelines for the German Respiratory Society (DGP) e. V. (AWMF registration number 020-030)]

Bronchiectasis is an etiologically heterogeneous, chronic, and often progressive respiratory disease characterized by irreversible bronchial dilation. It is frequently associated with significant symptom burden, multiple complications, and reduced quality of life. For several years, there has been a marked global increase in the prevalence of bronchiectasis, which is linked to a substantial economic burden on healthcare systems. This consensus-based guideline is the first German-language guideline addressing the management of bronchiectasis in adults. The guideline emphasizes the importance of thoracic imaging using CT for diagnosis and differentiation of bronchiectasis and highlights the significance of etiology in determining treatment approaches. Both non-drug and drug treatments are comprehensively covered. Non-pharmacological measures include smoking cessation, physiotherapy, physical training, rehabilitation, non-invasive ventilation, thoracic surgery, and lung transplantation. Pharmacological treatments focus on the long-term use of mucolytics, bronchodilators, anti-inflammatory medications, and antibiotics. Additionally, the guideline covers the challenges and strategies for managing upper airway involvement, comorbidities, and exacerbations, as well as socio-medical aspects and disability rights. The importance of patient education and self-management is also emphasized. Finally, the guideline addresses special life stages such as transition, family planning, pregnancy and parenthood, and palliative care. The aim is to ensure comprehensive, consensus-based, and patient-centered care, taking into account individual risks and needs.

Prevalence of chronic rhinosinusitis and its relating factors in patients with bronchiectasis: findings from KMBARC registry

BACKGROUND/AIMS

Patients with bronchiectasis often present with respiratory symptoms caused by chronic rhinosinusitis (CRS). However, studies on the prevalence of CRS and its relationship with bronchiectasis are limited.

METHODS

The baseline characteristics of patients with bronchiectasis recruited from the Korean Multicenter Bronchiectasis Audit and Research Collaboration were analyzed. CRS diagnosis was determined by a physician, on the basis of medical records, upper airway symptoms, and/or radiologic abnormalities. Questionnaires for quality of life, fatigue, and depression were administered when patients were stable for a minimum of 4 weeks after the bronchiectasis exacerbation.

RESULTS

The prevalence of CRS was 7.1% (66/931). Patients with CRS were significantly younger than those without CRS (60.5 ± 10.7 years vs. 64.6 ± 9.3 years, p = 0.001). Idiopathic bronchiectasis was more common in patients with CRS compared to those without CRS (53.0% vs. 36.0%, p = 0.006). Lung function, inflammatory markers, exacerbations, bronchiectasis severity, and scores for quality of life, fatigue, and depression did not differ between the two groups. In a logistic regression analysis, CRS was associated with age of bronchiectasis diagnosis (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.94 to 0.99; p = 0.003) and idiopathic bronchiectasis (OR, 1.95; 95% CI, 1.12 to 3.34; p = 0.018).

CONCLUSION

The prevalence of CRS was relatively low. CRS was not associated with the severity or clinical outcomes of bronchiectasis. Early diagnosis and idiopathic etiology were associated with CRS. Our findings reflect the low recognition of CRS in the clinical practice of bronchiectasis and highlight the need for awareness of CRS by adopting objective diagnostic criteria.

The clinical impact of self-reported symptoms of chronic rhinosinusitis in people with bronchiectasis

BACKGROUND

Chronic rhinosinusitis affects 62% of adults with bronchiectasis and is linked to greater bronchiectasis severity. However, the impact of symptoms of chronic rhinosinusitis on disease-specific and cough-related quality of life is unknown.

METHODS

In this cross-sectional study, adults with stable bronchiectasis and chronic rhinosinusitis symptoms completed the sinonasal outcome test-22 (SNOT-22), quality of life-bronchiectasis questionnaire, and Leicester cough questionnaire. Bronchiectasis severity was assessed using the bronchiectasis severity index (BSI) and chest high-resolution computed tomography (HRCT).

RESULTS

Sixty participants with bronchiectasis (mean [SD] forced expiratory volume in 1 s of 73.2 [25.5] %predicted) were included. Greater severity of chronic rhinosinusitis symptoms (based on SNOT-22) was moderately associated with impaired cough-related quality of life (according to the Leicester cough questionnaire; all r > -.60) and impaired bronchiectasis-specific quality of life (based on the quality of life-bronchiectasis questionnaire), with impaired physical function (r = -.518), less vitality (r = -.631), reduced social function (r = -.546), greater treatment burden (r = -.411), and increased severity of respiratory symptoms (r = -.534). Chronic rhinosinusitis symptoms were unrelated to disease severity according to the BSI (r = .135) and HRCT scoring (all r < .200). The severity of chronic rhinosinusitis symptoms was not affected by sputum color (p = .417) or the presence of Pseudomonas aeruginosa colonization (p = .73).

CONCLUSIONS

In adults with bronchiectasis, chronic rhinosinusitis has a consistent and negative impact on both cough-related and bronchiectasis-specific quality of life.

Effects of pain on depression, sleep, exercise tolerance, and quality of life in patients with nontuberculous mycobacterial pulmonary disease

The experience and causes of pain in patients with nontuberculous mycobacterial pulmonary disease (NTM-PD) have not been clarified.This study aimed to determine the prevalence and severity of bodily pain (BP) in patients with NTM-PD. We also investigated the clinical indicators that contribute to pain.We used a retrospective cross-sectional study design. The participants were 114 NTM-PD patients (109 women) with a mean age of 65 years. The prevalence and severity of pain were measured using 2 items from the 36-Item Short Form Survey version 2 (SF-36), and the BP score was calculated. Functional limitation due to dyspnea was quantified using the Modified Medical Research Council Dyspnea Scale (mMRC), depression was assessed using the Center for Epidemiological Studies Depression Scale (CES-D), sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI); health-related quality of life was assessed using the Leicester Cough Questionnaire (LCQ), and exercise tolerance was measured using the Incremental Shuttle Walk Test (ISWT).Pain was reported by 70.2% of the patients (n = 80), and of these, 35.7% (n = 25) reported moderate to very severe pain. NTM-PD patients with high levels of pain had significantly higher scores on the mMRC, CES-D, and PSQI scores, and significantly lower performance on the ISWT and LCQ. Multiple regression analysis identified ISWT, CES-D, and PSQI as independent factors that affected BP scores.Our findings suggest that pain significantly impacts daily life associated with reduced exercise tolerance, the presence of depressive symptoms, and poor sleep quality in patients with NTM-PD.

The Link between Asthma and Bronchiectasis: State of the Art

The nonrecognition of asthma-associated comorbidities is often responsible for the therapeutic failure and the worsening of symptoms, and it is associated with frequent exacerbations, higher disease severity, and increased health costs. Bronchiectasis, one of the most frequent asthma-associated comorbidities, can increase airways inflammation and exacerbation rates and cause respiratory functional impairment. The aim of this article is to review the interactions between bronchiectasis and asthma, in order to better identify patients in the overlap between the 2 diseases and to select an "ad hoc" therapy. A literature search on PubMed/MEDLINE was performed using the following search terms: bronchiectasis in asthma, the association between asthma and bronchiectasis, comorbidities in asthma, and severe asthma. This review analyzed the following items: incorrect or underestimated diagnosis of asthma and bronchiectasis, prevalence of bronchiectasis in asthma, the impact of bronchiectasis in asthma, radiological imaging features of the 2 diseases, etiopathogenesis, and common causes (such as gastroesophageal reflux disease, immune deficits, chronic rhinosinusitis and allergic bronchopulmonary aspergillosis, and treatment of asthma and bronchiectasis). The concomitant presence of bronchiectasis and asthma should be suspected and investigated in patients with severe asthma, frequent exacerbations, and not responding to standard therapy. This clinical phenotype, characterized by a more severe disease, worse outcomes, and functional decline, must be readily recognized in order to choose the most appropriate therapeutic approach, able to potentially improve the management of bronchial asthma, to prevent the onset of exacerbations as well the functional decline, and to reduce health costs.

Prevalence and characterization of chronic rhinosinusitis in patients with non-cystic fibrosis bronchiectasis at a tertiary care center in the United States

BACKGROUND

Chronic rhinosinusitis (CRS) is associated with bronchiectasis; however, this relationship has not been well studied in the United States (US) population. In this work we aimed to determine the prevalence of CRS among patients with bronchiectasis affiliated with a US tertiary medical center and identify which comorbid diseases are associated with the presence of CRS in patients with bronchiectasis.

METHODS

This was a retrospective cohort study in which data were obtained from a large database warehouse at a tertiary care center. Patients with bronchiectasis were identified from 2007 to 2017 using diagnosis codes from the the ninth and tenth revisions of the International Classification of Diseases (ICD-9/10) and confirmed by radiographic evidence of bronchiectasis on chest computed tomography (CT) scans. Patients were divided into cohorts based on presence or absence of concomitant CRS. Characteristics analyzed included demographics, comorbidities, peripheral eosinophil counts, and pulmonary function testing.

RESULTS

CRS was present in 45% (408 of 900) of patients with bronchiectasis. Females represented a majority of bronchiectasis patients, both with and without CRS (69% and 64%, respectively, p = 0.09). After controlling for demographic factors, asthma (p < 0.01), allergic rhinitis (p < 0.01), gastroesophageal reflux disease (p < 0.01), and antibody deficiency (p < 0.01) were associated with the presence of CRS in patients with bronchiectasis.

CONCLUSION

CRS had a high prevalence and was associated with numerous comorbid conditions in patients with bronchiectasis. These findings have clinical implications for the treatment of patients with bronchiectasis and future research.

Prevalence of atopy and allergic rhinitis in patients with adult non-cystic fibrosis bronchiectasis

Background/aim

Non-cystic fibrosis bronchiectasis (non-CF BR) is common in developing countries.Limited data are available regarding the impact of atopy, and no data are available regarding allergic rhinitis in patients with adult bronchiectasis.The aim of this study was to evaluate the prevalence of atopy and allergic rhinitis in the clinical conditions of patients with BR.

Materials and methods

The study enrolled 101 patients who were diagnosed with non-CF BR using high-resolution computed chest tomography. Allergic rhinitis (AR) was defined by skin prick test (SPT) positivity and the presence of any nasal symptoms (watery runny nose, nasal obstruction, nasal itching, and sneezing).

Results

The mean age of patients was 48 ± 15 years (range 18–82); 55 (54.5%) patients were female. SPT positivity was detected in 37 (36.6%) cases. AR was detected in 32 (31.7%) patients with non-CF BR. AR was related to dyspnea (P = 0.04) and number of admissions to an emergency department in the previous year (P = 0.01). Forced expiratory volume in 1 s and forced vital capacity in patients with and without AR were different (P = 0.01 and P = 0.01, respectively). AR was correlated with number of admissions to an emergency department in the last year (r = 0.417, P = 0.005).

Conclusion

We concluded that atopy was detected in more than one-third of adult non-CF BR patients. This study demonstrated that non-CF BR patients might have AR; it might be important to be aware of nasal symptoms in non-CF BR patients.

Prevalence and Clinical Implications of Chronic Rhinosinusitis in People with Bronchiectasis: A Systematic Review

BACKGROUND

Chronic rhinosinusitis (CRS) is an extrapulmonary manifestation in some individuals with bronchiectasis, but the prevalence of CRS in this population and its clinical impact has not been systematically reviewed.

OBJECTIVE

To systematically review the prevalence of CRS in bronchiectasis and identify its clinical implications.

METHODS

Four databases were searched from inception to August 2018 for studies reporting the prevalence and/or clinical impact of CRS in individuals with bronchiectasis. Clinical outcomes included health-related quality of life (HRQOL), severity of bronchiectasis, lung function, clinical and psychological symptoms, exacerbation frequency, and health care utilization. Two independent reviewers rated the quality of evidence using the risk of bias for prevalence trials tool.

RESULTS

Of 80 studies identified, 8 studies with 797 participants (all adults) were included. Mean FEV₁ % predicted was 77.7%. Overall, 5 studies were classed as low risk of bias and 3 were of moderate risk of bias. The pooled prevalence of clinical and/or radiological CRS was 62% (95% CI, 50%-74%). CRS was associated with a greater degree of bronchiectasis severity, poorer HRQOL, reduction in smell detection, elevated levels of inflammatory markers, and reduced time to first exacerbation. However, the association with airflow obstruction was inconsistent and there was no impact on anxiety or depression.

CONCLUSIONS

CRS is present in 62% of adults with bronchiectasis. Its presence is associated with poorer HRQOL, greater degree of disease severity, and more extensive radiological bronchiectasis.

The economic burden of bronchiectasis - known and unknown: a systematic review

Background

The increasing prevalence and recognition of bronchiectasis in clinical practice necessitates a better understanding of the economic disease burden to improve the management and achieve better clinical and economic outcomes. This study aimed to assess the economic burden of bronchiectasis based on a review of published literature.

Methods

A systematic literature review was conducted using MEDLINE, Embase, EconLit and Cochrane databases to identify publications (1 January 2001 to 31 December 2016) on the economic burden of bronchiectasis in adults.

Results

A total of 26 publications were identified that reported resource use and costs associated with management of bronchiectasis. Two US studies reported annual incremental costs of bronchiectasis versus matched controls of US$5681 and US$2319 per patient. Twenty-four studies reported on hospitalization rates or duration of hospitalization for patients with bronchiectasis. Mean annual hospitalization rates per patient, reported in six studies, ranged from 0.3–1.3, while mean annual age-adjusted hospitalization rates, reported in four studies, ranged from 1.8–25.7 per 100,000 population. The average duration of hospitalization, reported in 12 studies, ranged from 2 to 17 days. Eight publications reported management costs of bronchiectasis. Total annual management costs of €3515 and €4672 per patient were reported in two Spanish studies. Two US studies reported total costs of approximately US$26,000 in patients without exacerbations, increasing to US$36,00–37,000 in patients with exacerbations. Similarly, a Spanish study reported higher total annual costs for patients with > 2 exacerbations per year (€7520) compared with those without exacerbations (€3892). P. aeruginosa infection increased management costs by US$31,551 to US$56,499, as reported in two US studies, with hospitalization being the main cost driver.

Conclusions

The current literature suggests that the economic burden of bronchiectasis in society is significant. Hospitalization costs are the major driver behind these costs, especially in patients with frequent exacerbations. However, the true economic burden of bronchiectasis is likely to be underestimated because most studies were retrospective, used ICD-9-CM coding to identify patients, and often ignored outpatient burden and cost. We present a conceptual framework to facilitate a more comprehensive assessment of the true burden of bronchiectasis for individuals, healthcare systems and society.

Electronic supplementary material

The online version of this article (10.1186/s12890-019-0818-6) contains supplementary material, which is available to authorized users.

Precision medicine in united airways disease: A "treatable traits" approach

United airways disease (UAD) is the concept that the upper and lower airways, which are anatomically and immunologically related, form a single organ. According to this concept, upper and lower airway diseases are frequently comorbid because they reflect manifestations of a single underlying disease at different sites of the respiratory tract. Allergic asthma-allergic rhinitis is the archetypal UAD, but emerging data indicate that UAD is a heterogeneous condition and consists of multiple phenotypes (observable clinical characteristics) and endotypes (pathobiologic mechanisms). The UAD paradigm also extends to myriad sinonasal diseases (eg, chronic rhinosinusitis with or without nasal polyps) and lower airway diseases (eg, bronchiectasis, chronic obstructive pulmonary disease). Here, we review currently known phenoendotypes of UAD and propose a "treatable traits" approach for the classification and management of UAD, wherein pathophysiological mechanisms and factors contributing to disease are identified and targeted for treatment. Treatable traits in UAD can be analyzed according to a framework comprising airway inflammation (eosinophilic, neutrophilic), impaired airway mucosal defense (impaired mucociliary clearance, antibody deficiency), and exogenous cofactors (allergic sensitizers, tobacco smoke, microbes). Appreciation of treatable traits is necessary in advancing the effort to deliver precise treatments and achieve better outcomes in patients with UAD.

The overlap between bronchiectasis and chronic airway diseases: state of the art and future directions

Bronchiectasis is a clinical and radiological diagnosis associated with cough, sputum production and recurrent respiratory infections. The clinical presentation inevitably overlaps with other respiratory disorders such as asthma and chronic obstructive pulmonary disease (COPD). In addition, 4-72% of patients with severe COPD are found to have radiological bronchiectasis on computed tomography, with similar frequencies (20-30%) now being reported in cohorts with severe or uncontrolled asthma. Co-diagnosis of bronchiectasis with another airway disease is associated with increased lung inflammation, frequent exacerbations, worse lung function and higher mortality. In addition, many patients with all three disorders have chronic rhinosinusitis and upper airway disease, resulting in a complex "mixed airway" phenotype.The management of asthma, bronchiectasis, COPD and upper airway diseases has traditionally been outlined in separate guidelines for each individual disorder. Recognition that the majority of patients have one or more overlapping pathologies requires that we re-evaluate how we treat airway disease. The concept of treatable traits promotes a holistic, pathophysiology-based approach to treatment rather than a syndromic approach and may be more appropriate for patients with overlapping features.Here, we review the current clinical definition, diagnosis, management and future directions for the overlap between bronchiectasis and other airway diseases.

Upper airway involvement in bronchiectasis is marked by early onset and allergic features

The association of bronchiectasis with chronic rhinosinusitis (CRS) has been reported. However, apart from primary ciliary dyskinesia (PCD) and cystic fibrosis (CF), predisposing conditions have not been established. We aimed to define clinical and laboratory features that differentiate patients with bronchiectasis with upper airway symptoms (UASs) and without PCD from patients without UASs.

We reviewed charts of adults with bronchiectasis, excluding CF and PCD. UASs were defined as nasal discharge most days of the year, sinusitis or nasal polyps. Laboratory data included IgG, total IgE, blood eosinophils, sputum bacteriology and lung function. A radiologist blinded to UAS presence scored bronchiectasis (Reiff score) and sino-nasal pathology (Lund–Mackay score).

Of 197 patients, for the 70 (35%) with UASs, symptoms started earlier (34±25 versus 46±24 years; p=0.001), disease duration was longer (median 24 versus 12 years; p=0.027), exacerbations were more frequent (median 3 versus 2 per year; p=0.14), and peripheral blood eosinophil (median 230 versus 200 μL⁻¹; p=0.015) and total IgE (median 100 versus 42 IU·mL⁻¹; p=0.085) levels were higher. The sinus computed tomography score was independently associated with exacerbations, with 1 point on the Lund–Mackay score associated with a 1.03-fold increase in the number of exacerbations per year (95% CI 1.0–1.05; p=0.004).

These findings may implicate a higher disease burden in patients with UASs. We hypothesise that UASs precede and may in some cases lead to the development of bronchiectasis.

Involvement of the upper airway in patients with bronchiectasis is associated with an early age of onset and allergic featureshttp://ow.ly/1BuK30gWDrN

The validity of health-related quality of life questionnaires in bronchiectasis: a systematic review and meta-analysis

BACKGROUND

A range of questionnaires have been used to assess health-related quality of life (HRQOL) in bronchiectasis. A systematic review was conducted to evaluate their psychometric properties and assess associations between HRQOL and clinical measures.

METHODS

Five electronic databases were searched. Studies eligible for inclusion were those that investigated the validity of HRQOL questionnaires and/or their association with other outcomes in adults with bronchiectasis. Patients with cystic fibrosis were excluded. The identified questionnaires were assessed for convergent, discriminant and cross-cultural translation validity; missing data, floor and ceiling effects, internal consistency, responsiveness and test-retest reliability. A meta-analysis was conducted to estimate the strength of associations between HRQOL and clinical measures.

RESULTS

From 1918 studies identified, 43 studies were included in the systematic review, of which 38 were suitable for the meta-analysis. Nine HRQOL questionnaires were identified, with the most widely used being: St George's Respiratory Questionnaire, Leicester Cough Questionnaire, Quality of Life-Bronchiectasis and Short Form-36. HRQOL questionnaires had moderate to good internal consistency and good test-retest reliability. Only 8 of 18 studies that used translated HRQOL questionnaires reported or referred to the validity of the translated questionnaire. There was a stronger correlation (mean r (95% CI)) between HRQOL and subjective outcome measures, such as dyspnoea (0.55 (0.41 to 0.68)) and fatigue (0.42 (0.23 to 0.58)) compared with objective measures; exercise capacity (-0.41 (-0.54 to -0.24)), FEV1% predicted (-0.31 (-0.40 to -0.23)) and extent of bronchiectasis on CT scan (0.35 (0.03 to 0.61)); all p<0.001.

CONCLUSIONS

This review supports most HRQOL questionnaires used in bronchiectasis have good psychometric properties. There was a weak to moderate association between HRQOL and objective outcome measures. This suggests that HRQOL questionnaires assess a unique aspect of health not captured by objective measures.

Health-related quality of life is inversely correlated with C-reactive protein and age in Mycobacterium avium complex lung disease: a cross-sectional analysis of 235 patients

Background

Mycobacterium avium complex (MAC) lung diseases generally cause chronic disease in immunocompetent hosts. Although a few studies have examined health-related quality of life (HRQL) in patients with MAC lung disease, there have been no large studies. This study aimed to evaluate HRQL and its correlation with clinical outcomes in MAC lung disease.

Methods

A cross-sectional study was conducted at Keio University Hospital to investigate the factors associated with HRQL in pulmonary nontuberculous mycobacterial diseases. MAC lung diseases were diagnosed according to the 2007 ATS/IDSA guidelines for nontuberculous mycobacterial diseases. The 36-item short form health survey (SF-36) was administered to assess clinical outcomes. Clinical variables included treatment status, latest haematological data, and bacterial smear and culture results.

Results

The SF-36 scores for the 235 patients (median age, 69 years; 45 men and 190 women) with MAC lung disease, except for the bodily pain and mental health subscale scores, were significantly lower than the Japanese population norms. In the multivariable analyses, current treatment for MAC and a positive sputum smear or culture within the past year were significantly associated with lower SF-36 scores. C-reactive protein (CRP) and age showed stronger inverse correlations with SF-36 scores.

Conclusions

HRQL, especially the physical component, was impaired in patients with MAC lung diseases; this appears to be related with current treatment status, positive sputum smear or culture within the previous year, and particularly CRP and age. Further studies including qualitative assessments are needed to investigate the efficacy of CRP as a marker for progression or treatment response in MAC lung disease.

Trial registration

Clinical trial registered with UMIN (UMIN000007964).

Impacts of Co-Existing Chronic Rhinosinusitis on Disease Severity and Risks of Exacerbations in Chinese Adults with Bronchiectasis

BACKGROUND

Mounting evidence supports the notion of "one airway, one disease."

OBJECTIVE

To determine whether chronic rhinosinusitis (CRS) poses adverse impacts on Chinese adults with bronchiectasis.

METHODS

We enrolled 148 consecutive adults with clinically stable bronchiectasis. CRS diagnosed based on the 2012 EP3OS criteria. We systematically evaluated the bronchiectasis etiology, radiology, lung function, sputum bacteriology, airway inflammatory biomarkers, Bronchiectasis Severity Index, cough sensitivity and healthcare resource utilization. All patients were prospectively followed-up for 1 year to examine the frequency of bronchiectasis exacerbations (BEs).

RESULTS

Forty-seven patients (31.8%) were diagnosed as having CRS. Bronchiectasis etiologies did not vary statistically between CRS and no-CRS group. There was a trend towards non-statistically higher Bronchiectasis Severity Index [6.4±3.4 vs. 5.0(6.0), P = 0.19], a higher proportion of patients with BEs needing hospitalization before enrollment (48.9% vs. 29.7%, P = 0.13), poorer FVC [78.2±19.8% vs. 82.2(16.8)%, P = 0.54] and FEV1 [68.2±24.8% vs. 74.8(21.2)%, P = 0.29], a higher prevalence of Pseudomonas aeruginosa isolated (36.2% vs. 26.7%, P = 0.27) or colonized in sputum (36.2% vs. 21.8%, P = 0.12) and greater capsaicin cough sensitivity [C2: 3.9(123.0) μmol/L vs. 11.7(123.0) μmol/L, P = 0.81; C5: 62.5(996.0) μmol/L vs. 250.0(973.0) μmol/L, P = 0.32]. Patients with CRS had significantly greater risks of experiencing BEs during follow-up (P = 0.02 for negative binominal regression test).

CONCLUSION

Chinese adults with bronchiectasis appear to have a lower prevalence of CRS than that in western countries. There was a trend towards greater adverse impacts on bronchiectasis in patients with CRS. Studies with greater sample sizes might help to resolve this issue. In future clinical practice, physicians should be vigilant to the screening of concomitant CRS in bronchiectasis so as to better improve patient's healthcare. Our findings may be of clinical significance in that proper treatment of upper airway symptoms due to CRS will be the prevention of infection or re-infection of the tracheobronchial tree, which should be addressed for the future management of bronchiectasis.

Influence of self-reported chronic rhinosinusitis on health-related quality of life: a population-based survey

Chronic rhinosinusitis (CRS) is a frequently occurring chronic respiratory disease. There is evidence that effective treatment of CRS can improve patients’ quality of life, but the data regarding the extent to which CRS impairs patients’ quality of life (QoL) is sparse. This study aimed to evaluate the effect of self-reported CRS on health-related QoL and to determine whether the influence was associated with gender, age and socio-economic status. A four-stage random sampling method was used to select the participants from the general population in Guangzhou, China. All participants were interviewed face-to-face at their homes using a standardized questionnaire. The health-related QoL of each participant was assessed using the SF-36 Health Survey. The scores of the SF-36 after adjusting for gender, age, socioeconomic conditions, smoking and some important comorbid conditions were compared between the CRS group and the non-CRS group using analysis of covariance. A multiple linear regression model with interaction terms was established to determine whether CRS affected QoL to the same degree across the different subpopulations. Among a total of 1,411 participants aged at least 15 years, 118 persons (8.4%) had self-reported CRS. Subjects with CRS had an increased prevalence of allergic rhinitis, chronic obstructive pulmonary disease and gout than subjects without CRS. The CRS group had lower scores in all eight domains and the physical and mental component summary than those without CRS (P<0.05), and the greatest differences were in role emotional function (RE), general health (GH) and role physical function (RP). The impairments of the CRS participants in RE and RP were greater among the females than the males. Moreover, physical domains were affected to greater degrees among the elderly and those with high-level education. In conclusion, CRS is a common chronic disorder. Persons with self-reported CRS perceived themselves as having impaired QoL in both the physical and mental domains. These findings shed new light on the health burden of CRS and should be taken into account by clinicians involved in the care of CRS patients.

The importance of smell in patients with bronchiectasis

BACKGROUND

The aim of the study was to evaluate the sense of smell in patients with bronchiectasis.

METHODS

Prospective controlled study was performed on 91 patients with bronchiectasis. Bronchiectasis patients were sub-classified depending on: the presence of chronic rhinosinusitis, with or without nasal polyps, and the bronchiectasis ethiology. Olfactory function was evaluated by means of the Barcelona Smell Test (BAST-24) olfactometry for detection, identification, and forced choice for the first and fifth cranial nerve dependent odours in comparison to a group of 120 healthy volunteers.

RESULTS

Most patients with bronchiectasis (80.2%) satisfied EP(3)OS criteria of chronic rhinosinusitis (CRS), and 26.4% presented nasal polyps (NP). Smell detection, identification, and forced choice tests were significantly (p < 0.001) worse in bronchiectasis patients than healthy controls for both the 1st and 5th CN. Among subgroups, patients with CRS presented a significant (p < 0.05) reduction in smell detection compared to both healthy controls and patients without CRS. Patients with both CRS and NP presented a significant (p < 0.01) reduction in both smell detection and forced choice compared to patients with CRS and without NP. Patients with bronchiectasis and primary humoral immunodeficiency had a poorer smell detection (p < 0.001) and forced choice (p < 0.001) compared with post-infective and idiopathic bronchiectasis patients.

CONCLUSIONS

Patients with bronchiectasis have a moderate loss of smell with a higher impairment in patients with CRS, being maximal in patients with NP. Patients with immunodeficiency bronchiectasis showed high prevalence of CRS, and therefore marked impairment on the sense of smell. The mechanism could be explained through a mixed ethiology (obstruction/inflammation).

Effects of pulmonary rehabilitation in bronchiectasis: A retrospective study

There is limited information about the benefits of pulmonary rehabilitation (PR) in patients with bronchiectasis. This study aimed to evaluate the effects of an out-patient PR program in patients with a primary diagnosis of bronchiectasis and to compare them with a matched COPD group who completed the same PR program. A retrospective review was conducted of patients with bronchiectasis or COPD who completed 6 to 8 weeks of PR at two tertiary institutions. The outcome measures were the 6-minute walk distance (6MWD) and Chronic Respiratory Disease Questionnaire (CRQ). Ninety-five patients with bronchiectasis completed the PR (48 male; FEV1 63 [24] % predicted; age 67 [10] years). Significant improvements in 6MWD (mean change 53.4 m, 95% CI 45.0 to 61.7) and CRQ total score (mean change 14.0 units, 95% CI 11.3 to 16.7) were observed immediately following PR. In patients with complete follow-up (n = 37), these improvements remained significantly higher than baseline at 12 months (20.5 m, 95% CI 1.4 to 39.5 for 6MWD; 12.1 points, 95% CI 5.7 to 18.4 for CRQ total score). The time trend and changes in the 6MWD and CRQ scores were not significantly different between the bronchiectasis and the COPD groups (all p > 0.05). This study supports the inclusion of patients with bronchiectasis in existing PR programs. Further prospective RCTs are warranted to substantiate these findings.

Controversies in the treatment of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) including nasal polyps is a chronic inflammatory disease involving the mucosa of the nose and one or more paranasal sinuses. Despite differing hypotheses, the cause remains poorly understood. The key issue is the maintaining of ostial patency. CRS with nasal polyps is considered to be a subgroup of CRS. Major symptoms are nasal congestion or blockage, loss of smell, rhinorrhea, post-nasal drip, and facial pain or pressure. CRS is associated with lower airway disease such asthma, chronic obstructive pulmonary disease and bronchiectasis. In CRS with and without nasal polyps, medical treatment, including nasal and oral corticosteroids, is the first therapeutic option. The treatment of CRS still remains an unmet need. Corticosteroids are the mainstay of treatment and are the most effective drugs for treating airway inflammatory diseases such as asthma, allergic rhinitis and CRS. Endoscopic sinus surgery is only recommended when medical treatment fails. After surgery, medical treatment, including nasal and oral corticosteroids, is recommended.

Antileukotrienes in rhinosinusitis and nasal polyposis

Nasal polyposis is a chronic inflammatory disease of the nasal and paranasal sinus mucosa that, despite different hypotheses of its cause, remains poorly understood. The management of nasal polyposis has been the topic of countless frequent controversial debates for many decades. International guidelines generally suggest that first-line treatment should be based on a medical approach with mainly nasal and oral corticosteroids. Surgical procedures are often viewed as adjunctive to medical therapy. Given that antileukotrienes are currently indicated in the treatment of asthma and allergic rhinitis and there exists an increased leukotriene production in nasal polyps, antileukotrienes, especially montelukast, may represent a potential effective therapy for chronic rhinosinusitis, including nasal polyps.

United airways: the impact of chronic rhinosinusitis and nasal polyps in bronchiectasic patient's quality of life

BACKGROUND

The nose and the bronchi belong, in anatomical and physiopathological terms, to the concept of united airways. Associations between upper and lower airways diseases have been demonstrated in allergic rhinitis and asthma, nasal polyposis (NP) and asthma, chronic rhinosinusitis (CRS) and chronic obstructive pulmonary disease, and more recently CRS/NP and bronchiectasis (BQ).

OBJECTIVE

To evaluate the impact of CRS on quality of life (QoL) of patients with BQ, and to correlate these findings with the pulmonary status, nasal symptoms, and general health status.

METHODS

In a prospective study, patients with BQ (n = 80) were evaluated for CRS and NP using EP(3)OS criteria, and severity of BQ using chest high resolution computed tomography (HRCT)-scan. Quality of life was assessed in all patients by using specific [Sinonasal Outcome Test-20 (SNOT-20), St George Respiratory Questionnaire (SGRQ)], and generic (Short Form-36; SF-36) questionnaires.

RESULTS

Using SNOT-20, patients with CRS had worse QoL (2.1 +/- 0.1; P < 0.001) than patients without CRS (0.4 +/- 0.06). Using SGRQ total score, patients with CRS had worse QoL (43.7 +/- 2.2; P < 0.001) than patients without CRS (24.7 +/- 2.5). Using SF-36, patients with CRS had worse QoL, both in the physical summary (64 +/- 3.4; P < 0.05) and the mental summary (65.5 +/- 4.7; P < 0.05), than patients without CRS (physical summary [PS]: 76.2 +/- 3.3; mental summary [MS]: 78.3 +/- 5.3, respectively). Sinonasal Outcome Test-20 was correlated with SGRQ total score (r = 0.72; P < 0.01), and SF-36 physical summary (r = -0.63; P < 0.01). St George Respiratory Questionnaire was correlated with SF-36 on physical summary (r = -0.58; P < 0.05) and with forced expiratory volume in 1 s (r = -0.41; P < 0.05).

CONCLUSION

These results suggested that CRS, measured by both specific and generic questionnaires, has a considerable impact on the QoL of patients with BQ.

United airways again: high prevalence of rhinosinusitis and nasal polyps in bronchiectasis

BACKGROUND

Although various relationships between the lower and upper airways have been found, the association of bronchiectasis with chronic rhinosinusitis and nasal polyps has not been thoroughly evaluated. This study was undertaken to examine the association of idiopathic and postinfective bronchiectasis with chronic rhinosinusitis and nasal polyposis.

METHODS

In a prospective study, 56 patients with idiopathic and 32 with postinfective bronchiectasis were evaluated for chronic rhinosinusitis and nasal polyposis by using EP(3)OS criteria and assessing: symptoms score, nasal endoscopy, sinonasal and chest CT scan, nasal and lung function and nasal and exhaled NO.

RESULTS

Most bronchiectasis patients (77%) satisfied the EP(3)OS criteria for chronic rhinosinusitis, with anterior (98.5%) and posterior (91%) rhinorrhea and nasal congestion (90%) being the major symptoms. Patients presented maxillary, ethmoidal and ostiomeatal complex occupancy with a total CT score of 8.4 +/- 0.4 (0-24). Using endoscopy, nasal polyps with a moderate score of 1.6 +/- 0.1 (0-3) were found in 25% of patients. Nasal NO was significantly lower in patients with nasal polyposis (347 +/- 62 ppb) than in those without them (683 +/- 76 ppb; P < 0.001), and inversely correlated (R = -0.36; P < 0.01) with the ostiomeatal complex occupancy. In the chest CT scan, patients with chronic rhinosinusitis showed a higher bronchiectasis severity score (7.2 +/- 0.5; P < 0.001) than patients without (3.7 +/- 0.7). The prevalence of chronic rhinosinusitis, nasal polyps and other outcomes were similar in idiopathic and postinfective bronchiectasis.

CONCLUSIONS

The frequent association of chronic rhinosinusitis and nasal polyposis with idiopathic and postinfective BQ supports the united airways concept, and it suggests that the two type of bronchiectasis share common etiopathogenic mechanisms.

Chronic rhinosinusitis and nasal polyps: the role of generic and specific questionnaires on assessing its impact on patient's quality of life

Chronic rhinosinusitis (CRS) including nasal polyps is a chronic inflammatory disease of the nasal and paranasal sinus mucosa that, despite differing hypotheses of its cause, remains poorly understood. Primary symptoms are nasal blockage, loss of smell, rhinorrhea, and facial pain or pressure. Chronic rhinosinusitis causes significant physical symptoms, has a negative impact on quality of life (QoL), and can substantially impair daily functioning. A global evaluation of patients must include, together with nasal symptoms, nasal endoscopy, and CT scan, the measurement of QoL. To assess QoL in CRS, specific and generic questionnaires may be used. Chronic rhinosinusitis has a considerable impact on a patient's QoL but comorbidities, such as asthma and atopy, have an accumulative negative effect. Both medical and surgical treatments lead to a similar improvement on the QoL of CRS and nasal polyp patients.

Cyclooxygenases and the pathogenesis of chronic rhinosinusitis and nasal polyposis

Cyclooxygenase (COX) enzymes catalyze the rate-limiting steps in prostaglandin synthesis. Prostaglandins have an important role in several physiological processes such as maintenance of gastrointestinal integrity and pathological processes such as inflammation and neoplasia. Several mechanisms have been proposed for the development of chronic rhinosinusitis, but the common final pathway seems to be an integrated process involving the mucosal epithelium, matrix, and inflammatory cells and mediators. Upper and lower airway pathologies coexist and share common etiopathogenic mechanisms, and nasal polyposis is often associated with asthma and aspirin sensitivity. The cellular source of COX activity in acute and chronic inflammation, as in chronic rhinosinusitis, is poorly understood. COX theory postulated that inhibition of COX broke down biochemical reactions that lead to the development of asthma attacks. This article focuses on COX in the pathogenesis of chronic rhinosinusitis and nasal polyposis.